CPT codes are used to describe tests, surgeries, evaluations, and any other medical procedure performed by a healthcare provider on a patient. As you might imagine, this code set is extremely large, and includes the codes for thousands upon thousands of medical procedures.
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CPT codes are an integral part of the billing process. CPT codes tell the insurance payer what procedures the healthcare provider would like to be reimbursed for. As such, CPT codes work in tandem with ICD codes to create a full picture of the medical process for the payer. “This patient arrived with these symptoms (as represented by the ICD code) and we performed these procedures (represented by the CPT code).
Like ICD codes, CPT codes are also used to track important health data and measure performance and efficiency. Government agencies can use CPT codes to track the prevalence and value of certain procedures, and hospitals may use CPT codes to evaluate the efficiency and abilities of individuals or divisions within their facility.
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Let’s look a little closer at what these codes look like and how they’re organized. Each CPT code is five characters long, and may be numeric or alphanumeric, depending on which category the CPT code is in. Don’t confuse this with the ‘category’ in ICD. Remember that in ICD codes the ‘category’ refers to the first three characters of the code, which describe the injury or disease documented by the healthcare provider.
With CPT, ‘Category’ refers to the division of the code set. CPT codes are divided into three Categories. Category I is the most common and widely used set of codes within CPT. It describes most of the procedures performed by healthcare providers in inpatient and outpatient offices and hospitals. Category II codes are supplemental tracking codes used primarily for performance management. Category III codes are temporary codes that describe emerging and experimental technologies, services, and procedures.
Note that while CPT codes have five digits, there are not 99,000-plus codes. CPT is designed for flexibility and revision, and so there is often a lot of “space” between codes. Unlike ICD, each number in the CPT code does not correspond to a particular procedure or technology.
Here’s a closer look at the three categories of CPT codes.
Medical coders will spend the vast majority of their time working with Category I CPT codes. For the sake of simplicity, we’ll refer to the CPT codebook when we’re describing the code set. This book, which is updated yearly by the AMA and the CPT Editorial Board, is an essential tool for every medical coder. In the next few minutes, you’ll learn the basic layout, format, and instructions found in the CPT codebook.
Like the ICD code set and its division into chapters by type of injury or illness, Category I CPT codes are divided into six large sections based on which field of health care they directly pertain to. The six sections of the CPT codebook are, in order:Evaluation and Management Anesthesiology Surgery Radiology Pathology and Laboratory Medicine
CPT codes are, for the most part, grouped numerically. The codes for surgery, for example, are 10021 through 69990.
In the CPT codebook, these codes are listed in mostly numerical order, except for the codes for Evaluation and Management. These Evaluation and Management, or E&M, codes are listed at the front of the codebook for ease of access. Physician’s offices frequently use E&M codes for reporting a number of their services. The code 99214, for a general checkup, is listed in the E&M codes, for example.
Note also that some codes appear out of numerical sequence but near similar procedures. This may seems slightly confusing, but having these codes clustered near similar procedures prevents having to delete and resequence codes, and so is seen as a sort of necessary evil.
Here’s a quick look at the sections of Category I CPT codes, as arranged by their numerical range.Evaluation and Management: 99201 – 99499 Anesthesia: 00100 – 01999; 99100 – 99140 Surgery: 10021 – 69990 Radiology: 70010 – 79999 Pathology and Laboratory: 80047 – 89398 Medicine: 90281 – 99199; 99500 – 99607
Within each of these code fields, there are subfields that correspond to how that topic—say, Anesthesia—applies to a particular field of healthcare. For instance, the Surgery section, which is by far the largest, is organized by what part of the human body the surgery would be performed on. If you’d like to learn more about the anatomy and physiology terms used in the Surgery section, follow this link to Course 2-10. Likewise, the Radiology section is organized into sections on diagnostic ultrasound, bone and joint studies, radiation oncology, and other fields. Please refer to the eBook for a complete breakdown of the subfields used in each of the code fields.
Each of these fields has its own particular guidelines when it comes to use. For example, the Surgery section has a guideline for how to report extra materials used (such as sterile trays or drugs) and how to report follow-up care in the case of surgical procedures.
Like ICD codes, many CPT codes are arranged by indentation. If a procedure is indented below another code, the indented procedure is an important or noteworthy variation on the above procedure, and would replace the first code. Let’s take a look at an example of an indented code.
The code for “management of liver hemorrhage; simple suture of liver wound or injury” is 47350. This is a surgical procedure, and would be found in the surgery/digestive system portion of the CPT book.
It’s helpful to look at a code like this in two parts. The first, which comes before the semicolon, is the general procedure. In this case, that’d be “liver management.” The phrase that comes after the semicolon is additional, specific information. In this example, we could read the code as “liver management, with a simple suture of liver wound or injury.”
If, however, a doctor performed a more complicated procedure on a patient’s liver, 47350 would no longer be the correct code to use. If we look in the CPT manual, we find the code 47360 below 47350. Code 47360 reads “complex suture of liver wound or injury, with or without hepatic artery ligation.” That phrase is meant to take the place of the phrase that comes after the semicolon in code 47350.
You could therefore read code 47360 as “liver management, with complex suture of liver wound or injury, with or without hepatic artery ligation.”
CPT codes also have a number of modifiers. These modifiers are two-digit additions to the CPT code that describe certain important facets of the procedure, like whether the procedure was bilateral or was one of multiple procedures performed at the same time. CPT modifiers are relatively straightforward, but are very important for coding accurately. For this reason, we’ll cover them in a later video.
Like ICD codes, many CPT codes also have additional instructions featured below the code. These instructions, which are in parentheses below the code you’ve looked up, tell the coder that, in certain situations, another code might be better suited than the present code. For now, just recognize that the CPT code set has a number of instructions that inform the medical coder on how to best code the procedure performed. Remember that you always need to code to the highest level of specificity, and a miscoded procedure can be the difference between an accepted and rejected claim.
The CPT code set also instructs coders on when to use multiple codes, when to use codes in tandem with one another (add-on codes), and which codes are “modifier exempt.”
This is an awful lot of information to take in regarding Category I CPT codes, so let’s review briefly.
Category I CPT codes are numeric, and are five digits long.
They are divided into six sections: Evaluation and Management, Anesthesia, Surgery, Radiology, Pathology and Laboratory, and Medicine.
Each of these sections has its own subdivisions, which correspond to what type of procedure, or what part of the body, that particular procedure relates to.
The sections are grouped numerically, and, aside from Evaluation and Management, are in numerical order. That is, the codes for Anesthesia come before, or are “lower” than the codes for Pathology and Laboratory.
Each of these sections also has specific guidelines for how to use the codes in that section.
Certain codes have related procedures indented below them. These indented codes are important variations on the code above them, and denote different methods, outcomes, or approaches to the same procedure. For example, the code for the elevation of a simple, extradural depressed skull fracture is 62000. The code for the elevation of a compound or comminuted, extradural depressed skull fracture is 62005.
There are a few important CPT Modifiers, which provide additional information about the procedure performed. We’ll cover these in just a little bit.
Some codes have instructions for coders below them. These instructions are found in parentheses below the code, and they instruct the coder that there may be another, more accurate code to use.
Now that we’ve given you a brief glimpse of Category I CPT codes, let’s take a look at the next section of CPT.
These codes are five character-long, alphanumeric codes that provide additional information to the Category I codes. These codes are formatted to have four digits, followed by the character F. These codes are optional, but can provide important information that can be used in performance management and future patient care.
Here’s a quick example. If a doctor records a patient’s Body Mass Index (BMI) during a routine checkup, we could use Category II code 3008F, “Body Mass Index (BMI), documented.”
These codes never replace Category I or Category III codes, and instead simply provide extra information. They are divided into numerical fields, each of which corresponds with a certain element of patient care. For a list of these fields in oder as well as examples, please refer to our ebook and powerpoints.Composite password These codes combine a number of procedures that typically occur in conjunction with one main procedure. Example: 0001F: heart failure assessed (includes all of the following): Blood pressure measured Level of activity assessed Clinical symptoms of volume overload assessed Weight recorded Clinical signs of volume overload assessed Patient Managemenns Includes patient care provided for specific clinical purposes like pre- and postnatal care. Example: 0503F: Postpartum care visins Patient History Describes measures for select elements of patient history or symptom evaluation Example: 1030F: Pneumococcus immunization status assessed Physical Examicountry Example: 2014F: Mental status assessed Diagnostic/Screening Processes or Results Includes results of tests ordered, including clinical lab tests and radiological actions Example: 3006F: Chest X-ray documented and reviewed Therapeutic, Preventive, or Other Interventions Describes pharmacologic, procedural or behavioral therapiens Example: 4037F: influenza immunization ordered or administered Follow-up or Other Outcomes These codes describe the review and communication of test results to a patient, patient satisfaction, patient functional status, and patient morbidity or mortality Example: 5005F: patient counseled on self-examination for new or changing moles Patient Safety Includes codes that describe patient safety prewarns Example: 6015F: Patient receiving or eligible to receive foods, fluids, or medication by mouth Structural Measurens This short section includes codes that describe the setting of the delivered care, and also covers the capabilities of the healthcare provider Example: 7025F: patient information entered into a reminder system with a target due date for the next mammogram
There are not nearly as many Category II CPT codes as there are in Category I, and in general you will not use Category II nearly as much. Still, it is an important element of the CPT code set, and you should be familiar with the basics of Category II codes as you prepare for a career in the field.
The third category of CPT codes is made up of temporary codes that represent emergent or experimental services, technology, and procedures. In certain cases, you may find that a newer procedure does not have a Category I code. There are codes in Category I for unlisted procedures, but if the procedure, technology, or service is listed in Category III, you are required to use the Category III code.
Category III codes allow for more specificity in coding, and they also help health facilities and government agencies track the efficacy of new, emergent medical techniques.
Think of Category III as codes that may become Category I codes, or that just don’t fit in with Category I. Category I codes must be approved by the CPT Editorial Panel. This Panel mandates that procedures or services must be performed by a number of different facilities in different locations, and that the procedure is approved by the FDA. Due to the nature of emerging medical technology and procedures, it’s not always possible for an experimental procedure to meet these criteria, and thus become a Category I code.
Whether a Category III code becomes a Category I code or not, all Category III codes are archived in the CPT manual for five years. If at the end of this five year period the code has not been converted to Category I, this procedure must be marked with a Category I “unspecified procedure” code. When flipping through the Category III section of the CPT manual, you’ll notice that each of the codes has a phrase listing its sunset date below the code. Think of the sunset dates as expiration dates on the code.
Like Category II, these codes are five characters long, and are comprised of four digits and a terminal letter. In this case, the last letter of Category III codes is T. For example, the code for the fistulization of sclera for glaucoma, through ciliary body is 0123T.
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Now that you have a better idea of what CPT looks like, how it’s formatted, and when to use which category of codes, let’s dive a little deeper into modifiers and how CPT codes look in action.